GW1-2022-08814_Well Construction - GW1_20220909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris C Russell 14:WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3254 A 80 365
ft•
ft. I M
NC Well Contractor Certification Number 15-OUTER CASING'for:itiiild eased`wells OR:I INER' »i "Ileatile' :k
Russell Well Drilling, Inc. mom TO DIAMETER TIHCKNEss MATERIAL
0 ft 72 ft- 6.25 in SDR21 PVC
Company Name 16JNNER:CASING'ORT,UBING' ci6thc vtel'�closed-too ?
2.Well Construction Permit#:43757 FROM TO DIAMETER THICKNESS I MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft fL in.
Water Supply Well: 17 SCREEN ,. ;.
FROM I To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipallPublic fL fL in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) n, h• in.
❑hidustriallCommercial ❑Residential Water Supply(shared) 18.GROUT 2
01rrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 fL Grout Poured
❑Monitoring ❑Recovery fL ft
Injection Well:
fL ft
❑Aquifer Recharge. ❑Groundwater Remediation
191(SAND/GRAVEL-PACK'if;6`livable),
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 201DRELLING LOGI atteeh'idditionel:sheeti..Kiiecesse
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) o FROM 7 DESCRIPTION mtoy nardoess solurock m slze etc.
k• 87 �• Dirt
4.Date Well(s)Completed: 8-19-22 Well ID# 87 ft 365 ft Rock
5a.Well Location: fL R
Randal & Linda Hatfield ft IL StP 0 3 2022
Facility/Owner Name Facility ID#(ifapplicable) fL fL ^^
1375 Gunters Hill Rd, Boomer NC 28906 ft ft
Physical Address,City,and Zip
ft ft.
Wilkes 21:'REMARKS,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36' 07.770' N 081' 25.218' W - 8/26/2022
6.Is(are)the well(s): IRPermanent or ❑Temporary Si ature o£Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo I5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 365 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I00)
10.Static water level below top of casing: 80 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617;MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NG27699-1636
12.Well construction method:Air Drilled
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: I r
15 Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: HTH . Amount: 1 Cup
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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